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APPLICATION FOR PERMIT LOCAL HEALTH S 601 x .HAZENTON AVE STOCKTON, CAI Telephone (209) 466-6781 CopyD PERMIT EXPIRES TYEAR FROM DATE ISSUE (Complete in Triplicate) Application is hereby made t6 the San Joaquin local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with SanrJoaquin County Ordinance No.549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local health District. i qq ,�� PM i /O Job Address 2r9 1 G� h�� . — City �� Lot Size T Owner's Name Address / � fc r_ Phone g Contractor., J��a, + 5 zg G0&,.e* � license No. Phone TYPE OF WELL/PUMP: it NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 0 SEWER LINES DISPOSAL FLD. PROP. LINE rDISTANCE TO NEAREST: S'�EPTIC TANKr FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ,IJTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ED Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L�(Domestic/Private Gravel Pack ❑ Tracy Type of Casing dovzl Specifications 171 Public 171 Other F] Delta Depth of Grout Seal r Type of Grout �. I I Irrigation ."Appfox. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ d f; Well Destruction ❑ Well Diameter 1i Sealing Material (top 50'M ,c � Depth Filter Material (Below 50') TYPE OF SEPTIC WORK: INIEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public seweris; available within 200 feet.) installation will serve: Residence_ Commercial Other Number of living units: �` Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 'i SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.04 Method of Disposal Distance to nearest: Well Foundation Property.Line 1 LEACHING LINE L1 No. R Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line N SEEPAGE PITS I I` Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health OFstrict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such'manner as to become subject to workman's.,compensation laws of California.".Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for-halt required inspections. Complete drawing on reverse side. " Signed X �' -- Tide: Date: �` f ( g I FOR DEPARTMENT USE ONLY Application Accepted by I Date Area Pit or Grout inspection by I Date Final Inspection by Date R.. Additional Comments: ❑ Stk 466=6781 ❑ILodi 369-3621 D Ma eco a23-716i ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Pefmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ii FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. INFO CASH +.EH 13-24 1 REV.v/n 51 EH 14.26 111 - s P Ei